Abstract This chapter focuses on chronic low back pain caused by degenerative endplate disease. Animal and cadaver studies have shown this pain is transmitted from the vertebral endplate through the basivertebral nerve (BVN). In the setting of vertebral endplate disruption, there is an upregulation in the nerve endings of the BVN, and thus an increase in pain at this location. MRI in patients with degenerative endplate disease shows edema, which is characterized as Modic type I and type II change. Patients with chronic low back pain who have failed 6 months of conservative care and who have active Modic changes on MRI can be treated with a BVN ablation. The BVN is accessed with a cannula via a transpedicular approach. The target for the ablation is near the center of the lumbar and sacral vertebral bodies before the BVN arborizes to each endplate. Once proper access is obtained, ablation is performed at a constant 85°C for 15 minutes. The procedure takes approximately 30 minutes per level treated, and the patient returns home the same day. The evidence for BVN ablation is supported by two Level l randomized clinical trials. At this time, BVN ablation is approved for vertebral levels L3 to S1. Given the robust evidence and its relatively low risk profile, BVN ablation should be considered in patients who present with chronic low back pain.

Abstract The use of electrical stimulation for pain relief has been described since 15 AD, with the earliest documentation for gout treatment by contact with a torpedo fish (electric fish), discovered by the Roman physician Scribonius Largus.1 Since, many other scientists and physicians have experimented with electrical stimulation and pain relief, but it wasn't until 1967 that Dr. Norman Shealy, the pioneer of contemporary neuromodulation, decided to stimulate large fibers in the dorsal column of the spinal cord2, based on a new theory of pain mechanisms called the "gate-control" theory proposed a few years earlier.

BackgroundLumbar medial branch nerve radiofrequency ablation (LRFA) is an interventional procedure used to treat chronic lumbar facet joint pain. Because the medial branch nerves also innervate the multifidus muscle, it has been proposed that LRFA may pose a risk of multifidus atrophy and/or dysfunction. However, the quality and level of evidence to answer this clinical question have not been established. Therefore, this review aimed to systematically appraise the literature to discern whether the prevailing evidence substantiates the hypothesis in question.MethodsA systematic review compliant with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines was performed to evaluate the quality and level of evidence of studies reporting functional and/or structural changes in the multifidus muscle following LRFA.ResultsOnly five cohort studies met inclusion criteria. Two studies assessed changes in multifidus function following LRFA with confirmed denervation at electromyography and significant reduction in multifidus shear modulus with ultrasound shear wave elastography. Of the four studies that evaluated changes in multifidus structure with magnetic resonance imaging following LRFA, two demonstrated a decrease in cross-sectional area or an increase in fat infiltration, one demonstrated no change, and one revealed an apparent increase. Given the destructive nature attributed to LRFA, some degree of multifidus atrophy and/or dysfunction may be plausible, albeit with a very low certainty that relies on a restricted body of literature of modest quality and with a presence of high bias.ConclusionThere is a paucity of studies discussing the potential association between LRFA and multifidus atrophy and/or dysfunction. In light of the shortage of high-quality studies and the absence of standardized protocols to assess both changes in the structure and function of the multifidus subsequent to LRFA, there is a pressing need for more prospective studies with a high methodological rigor to comprehensively address and answer this enduring debate in clinical practice.

Lumbar radiculopathy due to impingement of nerve roots from facet hypertrophy and/or disc herniation can often coincide with vertebrogenic low back pain. This is demonstrated on MRI with foraminal stenosis and Modic changes. We examine the potential of using a combination of basivertebral nerve ablation (BVNA) and lumbar laminotomy as an alternative to traditional spinal fusion in specific patient populations. This unique combination of surgical techniques has not been previously reported in the medical literature. We report a man in his late 30s with chronic low back pain and lumbar radiculopathy, treated with BVNA and concurrent laminotomy. The patient reported progressive improvements in his mobility and pain over the next 2 years. We discuss the advantages of using this technique for lumbar radiculopathy and Modic changes compared with conventional surgical modalities.

Introduction:Sacroiliac joint (SIJ) pathology is typically diagnosed and treated with fluoroscopy-guided intraarticular injections. Most practitioners use only an anteroposterior (AP) or oblique view. Although injection into the periarticular space may yield adequate pain relief, intraarticular needle placement is imperative to identify SIJ pathology and plan future management. This study highlights the importance of obtaining an additional lateral view during fluoroscopy to better evaluate SIJ disease.Methods:A retrospective review of 38 patients who underwent fluoroscopy guided SIJ injection was conducted, for which IRB approval was granted by the MetroWest Medical Center Institutional Review Board. Patient demographics (age, sex, BMI) and pre- and post-operative numerical rating scale (NRS) scores were collected, and initial needle location was reviewed. Patients were placed into groups according to initial needle location. Statistical analysis was conducted using a Mann-Whitney U-test with significance defined as p < 0.05.Results:The 21 females and 17 males had a mean age and BMI of 70.5 years and 27.8 kg/m2, respectively. Thirty-one patients had initial intraarticular needle placement confirmed with lateral arthrogram, and 7 patients had initial periarticular needle placement, requiring needle readjustment in lateral confirmatory view. Both groups had similar demographic characteristics. No statistically significant differences were found between the two groups' mean NRS score improvement (p=0.108).Conclusion:Using only the AP or oblique view during needle placement results in miss rates of nearly 20% while adding a lateral view can lower miss rates to near 0%. While pain relief may be adequate in either case, proper diagnosis and future management relies upon accurate needle placement.

PURPOSE:Anterior column pain refers to axial low back pain (LBP) originating from the intervertebral disc or vertebral endplates (discogenic or vertebrogenic pain). We sought to assess the safety and effectiveness of intradiscal steroid injection (IDSI) in diagnosing and treating patients with LBP arising from the anterior column.PATIENTS AND METHODS:This is a retrospective chart review of 66 patients who underwent 77 injections in an outpatient, private practice setting for the treatment of chronic lower back with history and physical exam findings indicating an origin within the anterior column and magnetic resonance imaging (MRI) findings of Modic changes associated with disc degeneration of grade 4 or above on the modified Pfirrmann scale. Patients reported pain as measured by the numerical rating scale (NRS) before the injection, at the time of their follow-up, and their maximum pain relief. The primary outcome was the change in NRS before and after the injections. The secondary outcome determined if the changes in the subjects' NRS met the minimal clinically important change (MCIC) criteria for LBP. We conducted a statistical analysis using a paired sample t-test.RESULTS:There was a statistically significant difference between the pre-injection and follow-up NRS scores (p < 0.001) and a significant difference between pre-injection and maximum relief NRS scores (p < 0.001). Most subjects (55/77, 71.4%) met the MCIC to relieve their chronic LBP at the time of the follow-up evaluation.CONCLUSION:For patients with chronic LBP and degenerative endplate changes, IDSIs provided these patients with significant short-term pain relief from pain arising from the anterior column.

BACKGROUND:The utilization of neuromodulation therapy continues to grow as therapeutic indications expand. These conditions often present with comorbid physical, visual, and auditory impairments. Patients with disabilities in these categories may have difficulty operating their devices. Thus, reviewing the accessibility and inclusive design of neuromodulation devices is imperative to ensure equal access for patients of all ability levels. To date, the literature provides little insight into this topic.MATERIALS AND METHODS:Manufacturers of Food and Drug Administration-approved neuromodulation devices in the United States completed our electronic survey to assess neuromodulation device features, universal/inclusive design guidelines, and methods used to make the device accessible to patients with disabilities.RESULTS:We assessed 11 devices from seven manufacturers. Of those, there were six spinal cord, two peripheral nerve, and three deep brain stimulators. Of all respondents, 91% used universal inclusive design guidelines. Of the studied devices, 91% have an interface that uses visual feedback, and 82% have an interface that uses auditory feedback. All surveyed devices were reported to have an interface that requires physical handling.DISCUSSION:Our study found that most devices incorporate auditory signals, buttons with raised indentations, speech commands, or other useful features to assist those with visual disabilities. Visual interfaces may be sufficient for a patient with hearing impairment to use all the surveyed devices. However, dual sensory impairment presents a significant limitation in all devices surveyed. Furthermore, the biggest barrier to using neuromodulation devices was physical impairment because all surveyed devices require physical handling.CONCLUSIONS:Manufacturers have awareness of universal inclusive design principles. However, our study was unable to find a device that is accessible to all users regardless of ability. As such, it is critical to involve universal design principles to ensure that inclusive devices are available to improve patient adherence, treatment efficacy, and outcomes.

Objective Chronic low back pain (CLBP) is multifactorial in nature, with recent research highlighting the role of multifidus dysfunction in a subset of nonspecific CLBP. This review aimed to provide a foundational reference that elucidates the pathophysiological cascade of multifidus dysfunction, how it contrasts with other CLBP etiologies and the role of restorative neurostimulation. Methods A scoping review of the literature. Results In total, 194 articles were included, and findings were presented to highlight emerging principles related to multifidus dysfunction and restorative neurostimulation. Multifidus dysfunction is diagnosed by a history of mechanical, axial, nociceptive CLBP and exam demonstrating functional lumbar instability, which differs from other structural etiologies. Diagnostic images may be used to grade multifidus atrophy and assess other structural pathologies. While various treatments exist for CLBP, restorative neurostimulation distinguishes itself from traditional neurostimulation in a way that treats a different etiology, targets a different anatomical site, and has a distinctive mechanism of action. Conclusions Multifidus dysfunction has been proposed to result from loss of neuromuscular control, which may manifest clinically as muscle inhibition resulting in altered movement patterns. Over time, this cycle may result in potential atrophy, degeneration and CLBP. Restorative neurostimulation, a novel implantable neurostimulator system, stimulates the efferent lumbar medial branch nerve to elicit repetitive multifidus contractions. This intervention aims to interrupt the cycle of dysfunction and normalize multifidus activity incrementally, potentially restoring neuromuscular control. Restorative neurostimulation has been shown to reduce pain and disability in CLBP, improve quality of life and reduce health care expenditures.

Chronic low back pain is a worldwide leading cause of pain and disability. Degenerative disc disease has been the presumptive etiology in the majority of cases of chronic low back pain (CLBP). More recent study and treatments have discovered that the vertebral endplates play a large role in CLBP in a term defined as vertebrogenic back pain. As the vertebral endplates are highly innervated via the basivertebral nerve (BVN), this has resulted in a reliable target in treating patients suffering from vertebrogenic low back pain (VLBP). The application of BVN ablation for patients suffering from VLBP is still in its early stages of adoption and integration into spine care pathways. BVN ablation is grounded in a solid foundation of both pre-clinical and clinical evidence. With the emergence of this therapeutic option, the American Society of Pain and Neuroscience (ASPN) identified the need for formal evidence-based guidelines for the proper identification and selection of patients for BVN ablation in patients with VLBP. ASPN formed a multidisciplinary work group tasked to examine the available literature and form best practice guidelines on this subject. Based on the United States Preventative Task Force (USPSTF) criteria for grading evidence, gives BVN ablation Level A grade evidence with high certainty that the net benefit is substantial in appropriately selected individuals.

A major contributor to CLBP is neuroplastic changes involving peripheral and central sensitization, and impaired sensorimotor control, which lead to lumbar multifidus dysfunction1-6. The LMBN innervates the multifidus, which provides dynamic spinal stabilization. LMBN PNS has emerged as a novel treatment option5-6. Our objective was to review the current state of the literature and discuss future perspectives of this innovative therapy.

Chronic low back pain remains highly prevalent, costly, and the leading cause of disability worldwide. Symptoms are complex and treatment involves an interdisciplinary approach. Due to diverse anatomical etiologies, treatment outcomes with interventional options are highly variable. A novel approach to treating chronic axial low back pain entails the use of peripheral nerve stimulation to the lumbar medial branch nerve, and this review examines the clinical data of the two different, commercially available, non-spinal neuromodulation systems. This review provides the clinician a succinct narrative that presents up-to-date data objectively. Our review found ten clinical studies, including one report of two cases, six prospective studies, and three randomized clinical trials published to date. Currently, there are different proposed mechanisms of action to address chronic axial low back pain with different implantation techniques. Evidence suggests that peripheral nerve stimulation of the lumbar medial branch nerve may be effective in improving pain and function in patients with chronic axial low back pain symptoms at short and long term follow up, with good safety profiles. Further long-term data is needed to consider this intervention earlier in the pain treatment algorithm, but initial data are promising.

Objective: To describe functional outcomes following discharge from an acute inpatient rehabilitation facility (IRF) in patients following epilepsy surgery, comparing laser interstitial thermal therapy (LITT) versus surgical resection for epilepsy. Design: Retrospective case series. Setting: Academic tertiary hospital. Participants: Eight patients who received LITT (n = 3) or surgical resection (n = 5) for epilepsy. Interventions: Acute inpatient rehabilitation. Main Outcome Measures: Functional independence measure (FIM), seizure incidence, discharge destination. Level of Evidence: IV. Results: The epilepsy cohort demonstrated a FIM change of 38.88 (vs. national average 29.55), average length of stay (LOS) of 15.13 days (vs. 13.38 days), and LOS efficiency was 3.4 (vs. 2.68). No patients in the epilepsy cohort were discharged to acute care hospital compared to a national average of 9.82%. Eighty-seven percent in the epilepsy cohort discharged to home (vs. 77%) and 12.5% to skilled nursing facility (vs. 11.90%). Between the subset who received LITT and those who received surgical resection, there was no statistically significant change in mean total FIM change (43.7 vs. 36), FIM efficiency (5.3 vs. 2.2), or FIM change in subset measures of memory (0.5 vs. 0.25) or problem solving (0 vs. 0.8). There was no statistical significance between groups in adverse events, including seizure. Conclusions: Outcome measures in this population appear to be consistent with national outcome measures for other IRF diagnoses. This suggests that acute inpatient rehabilitation should be considered after patients undergo surgical intervention for epilepsy. However, a larger sample size and controlled studies are necessary before generalizations can be made. In addition, no statistically significant functional difference was seen between patients who underwent LITT or surgical resection.

Introduction: The ankle syndesmosis is a critical articulation between the distal tibia and fibula and is comprised of the anterior-inferior tibiofibular ligament (AITFL), interosseous ligament (IOL), interosseous membrane, posterior-inferior tibiofibular ligament (PITFL) and inferior transverse ligament (ITL) [1, 2]. The detrimental effects of syndesmotic malreduction have been documented in the literature [3-5]. An item of continued debate is the effect of clamp placement on accuracy of syndesmotic reduction. A previous cadaveric study demonstrated clamp placement in the anatomic axis of the syndesmosis results in the most accurate reduction of the syndesmosis, but clamps were only placed 10 mm from the tibiotalar joint [6]. The purpose of this study was to analyze the effect of clamp placement on syndesmotic reduction with respect to clamp orientation and location above the tibial plafond.

Double-bundle anterior cruciate reconstructions have led to an increased interest in quantifying anterolateral rotatory stability. The application of combined internal rotation and valgus torques to the knee can more nearly recreate the anterolateral subluxation that occurs in the pivot shift test in vitro compared to coupled internal rotation torque and anterior tibial loads.

The purpose of this study was to establish quantitative and qualitative radiographic landmarks for identifying the femoral and tibial attachment sites of the AM and PL bundles of the native ACL and to assess the reproducibility of identification of these landmarks using intraclass correlation coefficients. It was hypothesized that the radiographic positions of the AM and PL bundles could be defined in relation to anatomic landmarks and radiographic reference lines.

Background: Quantification of the overall anterior cruciate ligament (ACL) and anteromedial (AM) and posterolateral (PL) bundle centers in respect to arthroscopically pertinent bony and soft tissue landmarks has not been thoroughly assessed. Hypothesis: A standardized anatomical measurement method can quantitate the locations of the ACL and AM and PL bundle centers in reference to each other and anatomical landmarks. Study Design: Descriptive laboratory study. Methods: Quantification of the ACL and its bundle attachments was performed on 11 cadaveric knees using a radio frequency-tracking device. Results: The tibial ACL attachment center was 7.5 mm medial to the anterior horn of the lateral meniscus, 13.0 mm anterior to the retro-eminence ridge, and 10.5 mm posterior to the ACL ridge. The femoral ACL attachment center was 1.7 mm proximal to the bifurcate ridge and 6.1 mm posterior to the lateral intercondylar ridge. The tibial AM attachment center was 8.3 mm medial to the anteromedial aspect of the lateral meniscus anterior horn, 17.8 mm anterior to the retro-eminence ridge, and 5.6 mm posterior to the ACL ridge. The femoral AM attachment center was 4.8 mm proximal to the bifurcate ridge and 7.1 mm posterior to the lateral intercondylar ridge. The tibial PL bundle attachment center was 6.6 mm medial to the posteromedial aspect of the lateral meniscus anterior horn, 10.8 mm anteromedial to the root attachment of the lateral meniscus posterior horn, and 8.4 mm anterior to the retro-eminence ridge. The femoral PL bundle attachment center was 5.2 mm distal to the bifurcate ridge and 3.6 mm posterior to the lateral intercondylar ridge. Conclusion: The authors developed a comprehensive compilation of measurements of arthroscopically pertinent bony and soft tissue landmarks that quantitate the ACL and its individual bundle attachment centers on the tibia and femur. Clinical Relevance: These clinically relevant arthroscopic landmarks may enhance single- and double-bundle ACL reconstructions through improved tunnel placement.

Background An anatomical medial knee reconstruction has not been described in the literature. Hypothesis Knee stability and ligamentous load distribution would be restored to the native state with an anatomical medial knee reconstruction. Study Design Controlled laboratory study. Methods Ten nonpaired cadaveric knees were tested in the intact, superficial medial collateral ligament and posterior oblique ligament—sectioned, and anatomically reconstructed states. Each knee was tested at 0°, 20°, 30°, 60°, and 90° of knee flexion with a 10-N·m valgus load, 5-N·m external and internal rotation torques, and 88-N anterior and posterior drawer loads. A 6 degrees of freedom electromagnetic motion tracking system measured angulation and displacement changes of the tibia with respect to the femur. Buckle transducers measured the loads on the intact and reconstructed proximal and distal divisions of the superficial medial collateral ligament and the posterior oblique ligament. Results A significant increase was found in valgus angulation and external rotation after sectioning the medial knee structures at all tested knee flexion angles. This was restored after an anatomical medial knee reconstruction. The authors also found a significant increase in internal rotation at 0°, 20°, 30°, and 60° of knee flexion after sectioning the medial knee structures, which was restored after the reconstruction. A significant increase in anterior translation was observed after sectioning the medial knee structures at 20°, 30°, 60°, and 90° of knee flexion. This increase in anterior translation was restored following the reconstruction at 20° and 30° of knee flexion, but was not restored at 60° and 90°. A small, but significant, increase in posterior translation was found after sectioning the medial knee structures at 0° and 30° of knee flexion, but this was not restored after the reconstruction. Overall, there were no clinically important differences in observed load on the ligaments when comparing the intact with the reconstructed states for valgus, external and internal rotation, and anterior and posterior drawer loads. Conclusion An anatomical medial knee reconstruction restores near-normal stability to a knee with a complete superficial medial collateral ligament and posterior oblique ligament injury, while avoiding overconstraint of the reconstructed ligament grafts. Clinical Significance This anatomical medial knee reconstruction technique provides native stability and ligament load distribution in patients with chronic or severe acute medial knee injuries.

Background: Currently in double-bundle anterior cruciate ligament (ACL) reconstructions, the range of knee flexion angles that surgeons use for anteromedial (AM) and posterolateral (PL) bundle graft fixation spans from 0 degrees to 90 degrees for both bundle grafts. Despite the recent popularity of this procedure, no consensus exists on an optimal set of AM and PL graft fixation angles.Hypothesis: Graft fixation angles that simulate the native tensioning relationship of the AM and PL bundles will produce kinematic results similar to the intact knee, while graft fixation angles that do not simulate this relationship will under- or overconstrain the knee.Study design: Controlled laboratory study.Methods: Twelve cadaveric knees were biomechanically tested in the intact state, ACL-sectioned state, and a randomized order of 7 double-bundle ACL reconstructed states at multiple graft fixation angle combinations. For each test state, data were collected for 88 N anterior tibial loads, 10 N.m valgus torques, 5 N.m internal rotation torques, and 2 simulated pivot shift loads consisting of a 5 N.m internal rotation torque coupled with either a 10 N.m valgus torque or an 88 N anterior tibial load at 0 degrees, 20 degrees, 30 degrees, 60 degrees, and 90 degrees of knee flexion.Results: The AM and PL graft fixation angle combinations of 0 degrees/0 degrees (AM graft fixation angle/PL graft fixation angle), 60 degrees/0 degrees, 45 degrees/15 degrees, and 75 degrees/15 degrees restored normal laxity to the reconstructed knee in all of the biomechanical tests. The 30 degrees/30 degrees, 60 degrees/60 degrees, and 90 degrees/90 degrees graft fixation angle combinations significantly restricted knee laxity compared with the intact state in various biomechanical tests.Conclusion: We found that as long as the PL bundle graft was fixed between 0 degrees and 15 degrees, the AM graft could be fixed up to 75 degrees without restricting knee laxity. However, fixation of the PL graft at 30 degrees of knee flexion and above significantly overconstrained the knee. Clinical Relevance: This study provides a range of angles that can be used in double-bundle ACL reconstructions to restore normal knee stability without causing overconstraint.